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Stomach and DuodenumStomach and Duodenum• AnatomyAnatomy
• PhysiologyPhysiology
• Operative proceduresOperative procedures
• Gastric disordersGastric disorders
peptic ulcer diseases
tumors
structural disorders
inflammatory and infectious diseases
traumas
Peptic ulcer diseases• Major types ;
duodenal ulcer
gastric ulcer
stomal ulcer
• Other types ;
stress ulcer
ulcers caused by gastric irritants
steroid induced ulcer
Duodenal ulcer ;pathogenetic factors
• Increased acid secretion
• Environment ; 흡연 , NSAIDS, Helicobacter
• Mucosal defense ; decreased bicarbonate production,
decreased gastric prostaglandin production
Duodenal Ulcer : goals of operative therapy
• promotion of ulcer healing
• treatment of specific complications
• reduction of the possibility of recurrence
• minimization of postoperative side effects
surgically correctable components to reduce the acid secretion
• Cholinergic vagal stimuli
• Parietal cell mass
• Gastrin secretion
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Gastric effects of truncal vagotomy
• Decreased acid secretion
• Increased serum gastrin
• Gastrin cell hyperplasia
• Accelerated liquid emptying
• Altered emptying of solid
Nongastric effects of truncal vagotomy
• Decreased pancreatic exocrine secretion
• Decreased postprandial bile flow
• Increased gallbladder volume
• Diminished release of vagally mediated peptide hormones
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Duodenal Ulcer : operative procedures
• Truncal vagotomy and drainage
• Truncal vagotomy and antrectomy
• Parietal cell vagotomy
• Alternative methods
Duodenal Ulcer : choice of operation
• Location of ulcer• Indication for operation• Chronicity of the ulcer diathesis• Age and sex, nutritional status of the patient• Presence of concomitant illness• Stability of the patient during the perioperative
period• Experience and personal preference of the surgeon
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Intractability ; criteria
• Initial healing is delayed, so that ulceration persists at 3
months despite active drug therapy
• Ulcers recur within 1 year of initial healing despite
maintenance therapy
• The ulcer disease is characterized by cycles of prolonged
activity with brief or absent remissions
Operative procedures : intractability
• First choice; parietal cell vagotomy
• Alternatives ; truncal vagotomy and antrectomy
laparoscopic vagotmy
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Clinical features ; perforated duodenal ulcer
• Symptoms ; sudden onset of severe epigastric pain spreading throughout the abdomen, variable degree of shock
• Signs ; abdominal tenderness, rigidity
• Plain X-ray ; peritoneal free air
Differential diagnosis ; perforated duodenal ulcer
• Acute cholecystitis
• Acute pancreatitis
• Strangulation obstruction
• Acute appendicitis
• Perforation of other G-I tract
• Mesenteric thrombosis
Operative procedures : perforation
• Simple closure
• Definitive surgery
parietal cell vagotomy and omental patch
truncal vagotomy and pyloroplasty
truncal vagotomy and antrectomy
Indications for definitive operation
• No preoperative shock
• No life-threatening medical illness
• Perforation has been present for less than 48 hours
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Operative procedures : obstruction
• Truncal vagotomy and antrectomy
• Truncal vagotomy and gastrojejunostomy
• Parietal cell vagotomy with dilatation
Duodenal Ulcer : indications for operation
• Intractability
• Perforation
• Obstruction
• Hemorrhage
Indications for operative intervention ; duodenal ulcer bleeding
• Massive hemorrhage leading to shock
• Prolonged blood loss requiring continuing transfusion
• Recurrent bleeding during medical therapy or after endoscopic therapy
• Recurrent bleeding requiring hospitalization
Operative procedures : hemorrhage
• Truncal vagotomy and pyloroplasty with
suture ligation of bleeding vessel
• Truncal vagotomy and antrectomy
including ulcer or
suture ligation of bleeding vessel
Predisposing factors ; gastric conditions
• Acid and pepsin
• Gastric stasis
• Coexisting duodenal ulcer
• Duodenogastric reflux
• Gastritis
• Helicobacter pylori
Predisposing factors ; clinical conditions
• Chronic alcohol use
• NSAIDS
• Smoking
• Long-term steroid therapy
• Infection
• Intraarterial chemotherapy
Gastric Ulcer : goals of elective operation
• Primary goals ;
to excise the ulcer
to reduce acid/pepsin output
• Secondary goals ;
to minimize bile reflux and gastric stasis
Gastric ulcer : standard operations
• type I ; Distal gastrectomy and B-I anastomosis
• type II, III ; Distal gastrectomy with vagotomy
• type IV ;
TV and draiage and biopsy/excision of ulcer
Distal gastrectomy with ulcer excision
Distal gastrectomy with biopsy of ulcer
Proximal gastrectomy
Gastric Ulcer : indications for elective operation
• Failure to heal on optimal medical therapy
• Suspicion of malignancy
• Distal gastric obstruction
• Giant gastric ulcer
Bleeding gastric ulcer : operative procedures
• Gastric resection including ulcer
• simple oversewing
• excision of ulcer
with TV and drainage
without TV and drainage
New Surgical Strategy for Gastroduodenal Ulcer : New Surgical Strategy for Gastroduodenal Ulcer : Laparoscopic approachLaparoscopic approach
• Truncal vagotomy
• Thoracoscopic truncal vagotomy
• Parietal cell vagotomy
Stress Ulcer
• Multiple superficial mucosal erosions
after major physical trauma, shock,
sepsis, hemorrhage, respiratory failure,
or severe burns.
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